ECSTASY
DRUG CLASS
CNS Stimulant, Hallucinogen
OTHER NAMES

m
GENERAL
Ecstasy, a synthetic, psychoactive and hallucinogenic drug, is an amphetamine analogue and a selective serotonergic neurotoxin. Since becoming an illegal drug in 1985, it has thrived in the world of drug analogues; and, in its search for new-age use and abuse, it has danced its way into the hyperkinetic world of marathon rave parties. Today, ecstasy is the most commonly used designeer drug.
     Street ecstasy is usually not pure MDMA , but may be any combination of 3,4-methylenedioxyamphetamine (MDA, the love pill, the love drug, or speed for lovers), N-ethyl-methylenedioxyamphetamin (MDE, Eve), lysergic acid diethylamide (LSD), amphetamine, caffeine, heroin, or lactose. MDE produces effects similar to MDMA but turns the subject inwards.
HOW ECSTASY IS TAKEN
MDMA comes in the form of a white, crystalline powder which can be buffered and pressed into pills. The usual dose is 1 to 2 mg/kg body weight (125 to 180 mg). A 100 mg tablet usually costs around $20 ($8-$30). It may be ingested orally, placed under the tongue, added to juice or a carbonated beverage, snorted or injected.
     "Candyflipping" is the combined use of ecstasy and LSD.
     "Stacking" means taking three or more ecstasy tablets at once, mixing it with LSD, alcohol, methadone, amphetamine, cocaine, heroin, fentanyl, ketamine, GHB, or marijuana, taking the drugs in different phases of the evening in order to modify and modulate the high. Stacking, with its mixed effects of stimulation and sedation, increases the risk of overdose. Alcohol though diuresis, increases the risk of dehydration from the marathon rave dancing.
HOW ECSTASY WORKS
MDMA half-life is 6 hours, and onset of action varies greatly from person to person. Serotonin and dopamine is released into the brain; the serotonin surge induces the euphoric and effusive feeling of "love" or "ecstasy." The release of dopamine decreases the perception of pain. The release of neurotransmitters also decreases body temperature perception, and users of MDMA can overheat without feeling any discomfort.
THE ECSTASY "RUSH"
The rush is almost instantaneous 'rush,' occurring in approximately 30 to 45 seconds, lasting 15 to 30 minutes. There is a gradual descent back to pre-rush state as users experience a sudden clarity and intensification of perceptions, objects become "brighter and crisper," an inner sensation of happiness is felt and a sense of "loving" exudes, likewise, felt from the people around. At this point, a "booster dose" of MDMA is usually taken, hoping to prolong these sensations. Unfortunately, booster doses increase tolerance to the desired effects and an increase in the adverse effects of coming down. Occasionally, instead of the rush, "bubble bursting" occurs; a bad trip of anxiety, paranoia, nausea and panic.
     Thirty minutes to 3 hours after the initial rush or "coming on," users experience a "plateau" phase of less-intense feelings. During the plateau, repetitive or trance-like movements become extremely pleasurable, leading to long-lasting ecstatic states of "trance-dancing." Rhabdomyolysis can easily occur during this phase of extended activity.
THE AFTER "RUSH"
     The "coming down" phase occurs 3 to 6 hours after initial ingestion. During this phase, feelings of disappointments and other negative emotions (eg, depression, anxiety) can emerge, with sluggishness and residual effects lasting up to several days. It may take up to 6 to 7 hours to fall asleep after returning to "normal," despite extreme exhaustion.
    "Tuesday blues," a sluggish feeling lasting several days after ingestion,  results from a relative depletion of serotonin.
     Long-term effects are uncertain, but because of possible short-circuiting of the serotonin pathway, serotonin shortage and subsequent depression may occur.
ADVERSE EFFECTS OF ECSTASY USE
Addiction to concurrently used substances (eg, amphetamines, heroin, cocaine)
Anorexia, nausea and vomiting
Arrhythmias, tachycardia (rapid heart beat)
Coagulopathy (disseminated intravascular coagualtion)
Confusion
Coma
Convulsions
Death
Dehydration and electrolyte imbalances
Fatigue
Heat exhaustion and injury (sometimes fatal, also referred to as "Saturday night fever")
Hepatic toxicity
Insomnia
Jaw-clenching and teeth grinding
Muscle spasms
Renal failure (acute)
Rhabomyolysis
Visual blurring
SCREENING
- MDMA is metabolized in the liver to MDA, which is then excreted in the urine; thus, typical urine drug tests may only detect MDA.
- Urine toxicology testing picks up certain other drugs simultaneously ingested, including alcohol, cannabis, hallucinogens, phencyclidine (PCP), or stimulants.
- A monoclonal immunoassay for amphetamine or methamphetamine detects MDMA if the drug was taken in large doses. Thin-layer chromatography can also detect MDMA metabolites in the urine. Whenever amphetamines are found on immunoassay screening tests, the results can be confirmed by gas chromatography or mass spectrometry.
MANAGEMENT OF OVERDOSE
- Management of acute heat injury in MDMA users includes rapid rehydration and core cooling.
- Management of rhabdomyolysis involves rehydration, correction of electrolyte imbalances, urine alkalinization, and furosemide as needed.
- For agitation, panic reactions or seizures, short-acting benzodiazepines can be administered intravenously or intramuscularly.
- Neurologic assessments and vital signs should be checked frequently.
- Muscle spasms: Dantrolene.
- Cardiac arrhythmias: Beta-blockers, calcium channel blockers, or procainamide. 

MARIJUANA
OTHER NAMES

GENERAL INFO
Probably used in the Neolithic age. Introduced to the Americas in the mid-19th century.
Controversial but increasing medical use.
AMA calling for additional control for use by seriously ill patients.
POSSIBLE FUTURE
Vaporization devices that deliver marijuana for pain, appetite, nausea and/or spasticity without the negative effects of smoke inhalation

DEXTROMETHORPHAN
OTHER NAMES
Triple C. skittles, red hots: street names for Coricidin, the most popular destromethorphan cough-and-cold medication used in dextromethorphan abuse.
GENERAL INFO
Dextromethorpahn was first approved in 1958 for use in cough medications. Intended to replace codeine, its abuse potential was quickly noted, and the first dextromethorphan product, Romilar, was quickly taken off its over-the-counter labeling and access. Subsequent dextromethorphan-containingcough medications were intentionally made unpleasant tasting to discourage abuse. However extraction-methods and ways to improve palatability, plus its accessibility, has kept in the menu of the teen drug abuse.
EFFECTS AND DERIVATIVES
The "high" is hallucinogenic, described as "LSD-like. Dextromethorphan is a pro-drug converted to the D-isomer of levorphanol, a semisynthetic morphine derivatIVE, noncompetitively antagonizing NMDA receptors. Possibly, it also affects serotonin receptors.

Highs and "plateaus" achieved depend on dosages:
First: a mild stimulant effect from a 100-200 mg dose.
Second: Intoxication with mild hallucinations, 200-400 mg).
Third: Most sought-after, an "out-of-body" experience, 300-600 mg or 14-16 tablets of Coricidin cough or cold tablets, each containing 30 mg of dextromethorphan hydrobromide.
ADVERSE EFFECTS
Above 600 mg, an unpleasant plateau is reached, characterized by full dissociation.
TREATMENT
Supportive.
Consider decontamination with activated charcoal as many of the source products contains an antihistamin which delays gastric emptying. The charcoal should be given for at least 6 hours.
Some reports suggest naloxone may reverse detromethorphan effects; some reports no benefits with naloxone.
TESTING
Toxicology screening do not specifically test for dextromethorphan.
The drug can cross-react with tests for PCP (phencyclidine).

The United States Congress passed a law called the Drug-Induced Rape Prevention and Punishment Act of 1996. Under this law, anyone who gives a person a drug without his or her knowledge in order to commit a violent crime can receive a fine and a sentence of up to 20 years in prison. Although date rape drugs have been used in clubs and bars, they can be used in any social setting. Three drugs are used of this purpose: Rohypnol, GHB, and ketamine.

GAMMA-HYDROXYBUTYRATE (GHB)
DRUG CLASS:
CNS Depressant
OTHER NAMES

GENERAL INFO
GHB is a precursor of the neurotransmitter gamma aminobutyric acid (GABA) that acts on the dopaminergic system. Available in several formulations: capsule form or as a salty, clear liquid in small bottles and is taken by the cupful. It is also found in liquid form in degreasers that mechanics use. GHB is undetectable when mixed with beverages.
     Developed as an adjunct to anesthesia in the 1979s, GHB was believed to have clinical value in the treatment of narcolepsy. In the 1980s, it was used by weight lifters to increase the metabolic rate. In the 1990s, "blue nitro," a GHB precursor, was used as a weight-loss preparation. Never proven as a muscle-growth stimulant, It was once popular as a perfomance-enhancing additive in body-building formulas (Serenity). It is used as a sedative coming down off stimulant highs of ephedrine, speed or cocaine. GHB's purported medicinal value was eventually overshadowed by its unpredictability; a given dose could completely anesthetize one patient and have no effect on another.
       Usually a product of clandestine labs with uncertain purity and quality, GHB is available in capsule, liquid (sold and consumed by the capful or teaspoon dose) and powder (dissolved in water or alcoholic beverages) formulation. A capful dose costs $3-$5 per dose.
HOW GHB WORKS
GHB's central nervous system effects include mediation of sleep cycles, temperature regulation, cerebral glucose metabolism and blood flow, memory, and emotional control. The onset of action is within 15 to 60 minutes, and effects last from 1 to 3 hours. The half-life is 27 minutes, with elimination by expired breath as carbon dioxide.
DESIRED EFFECTS OF GHB
It is taken to experience euphoria, disinhibition, and sexual enhancing effects without an appreciable hangover.
ADVERSE EFFECTS OF GHB
The concentration may vary, so the response is idiosyncratic and inconsistent from person to person. Patients may experience mydriasis or miosis. In severe cases, the classic triad of symptoms include coma, bradycardia, and myoclonus. Hallucinations can also occur.
     Other effects include nausea, vomiting, delusions, depression, altered mental status, apnea, hypotension, vertigo, respiratory distress, transient metabolic acidosis, loss of airway reflexes, ataxia, nystagmus, aggressive behavior, somnolence, anterograde amnesia, and coma.  As the patient starts to recover, "emergence phenomenon" can occur, characterized by myoclonic jerking motions, transient confusion, and combativeness, followed by rapid recovery of consciousness.
     Adverse effects are potentiated by alcohol, ketamine, benzodiazepines, major tranquilizers, opiates, anticonvulsants, and over-the-counter cold and sleep medications, increasing the risk of respiratory depression. Methamphetamine increases the risk of seizure.
MANAGEMENT OF GHB OVERDOSE
Management of CHB overdose consists of supportive therapy, including prevention of aspiration, IV fluids and oxygen as needed. Atropine is used in patients with persistent symptomatic bradycardia. In severe cases, rapid intubation with succinylcholine paralysis may be required for advanced airway protection. If multiple drug use is suspected, orogastric lavage and administration of activated charcoal with sorbitol is recommended. If intoxication persists beyond 6 hours after ingestion, hospital admission is warranted.
GHB PRECURSORS
A commonly found GHB precursor is gammabutyrolactone (GBL), also known as blue nitro, gamma-G, renewtrient, reviverent. GBL is an organic solvent used for cleaning circuit boards, stripping paint, or flavoring soy products. It acts like GHB but has a slower onset and a longer duration. Adverse effects include respiratory depression and cardiac dysrhythmia. It is metabolized in the liver into GHB but can also be made into GHB using home kits. Other precursors to GHB include tetramethylene glycol and 2(OH)-furanone dihydro.
POSSIBLE FUTURE
Treatment of fibromyalgia, chronic insomina, chronic fatigue syndrome, binge eating disorder.

KETAMINE
DRUG CLASS:
General Anesthetic, Hallucinogen
OTHER NAMES

GENERAL INFO
Developed in 1962 as an anesthetic. Used as a psychedilic throughout the 60s and 70s. Ketamine is a shorter-acting, less potent alternative to PCP. It is primarily a veterinary anesthetic, available in both liquid and powder forms. The liquid form is usually ingested orally and is bitter tasting, or administered intravenously. In white powder form it is either snorted or smoked with marijuana or tobacco. The powder can be made from the liquid by gently boiling on a stove or in the microwave.
     Dose-to-dose variability in effects is common, and the effects are potentiated by alcohol, barbiturates, opiates, GHB, and valium. If taken intramuscularly, effects occur within 15 to 20 minutes, or sooner on an empty stomach. Intranasally, the dose is repeated every 5 minutes until the desired effects are achieved.
DESIRED EFFECTS OF KETAMINE
Effects last 2 to 3 hours. Low doses lead to feelings of relaxation, and high doses bring on a sensation of near-death (known as the "K-hole") and loss of sense of time and identity. "K-land" refers to hallucinations and visual distortions. The user feels no pain, a state that can lead to unintentional injuries the user may not be aware of until he or she comes down.
ADVERSE EFFECTS
Short-term include tachycardia, hypertension, impaired motor function, respiratory depression. Short-term psychologic effects include dissociation, depression, recurrent flashbacks, delirium, and amnesia.
Long-term effects are currently unknown, but brain damage has been observed in animal studies. Use of ketamine with antibiotics (eg, floxacin), anticholinergics, antipsychotics, bupropion (Wellbutrin and Zyban), caffeine, or GHB increase the risk of seizure.
MANAGEMENT OF OVERDOSE
- Neuroleptic drugs are ineffective in controlling the unpleasant mental and visual side effects of ketamine.
- The clinician should watch for oversedation, protecting airways as necessary.
POSSIBLE FUTURE USE
•Treatment of heroin addiction, major depression and alcoholism.

ROHYPNOL
OTHER NAMES:
The date rape drug, ruffies, ruffles, roofies, rouches, roach, red, roche, rope, La Roche, the forget pill, the forget-me-pill, Run-Trip-and-Fall, R-2, Mexican Valium, Ropynol, Rib.
GENERAL INFO:
Manufactured and distributed by Hoffman-La Roche, flunitrazepam (Rohypnol, Noriel) is normally used as a hypnotic presurgical anesthetic. In Europe, Asia, and Latin America, it is licensed as an anti-seizure drug. In the US, however, where it has not received FDA approval, flunitrazepam has become infamous as a Mickey Finn, the "date rape drug."   Flunitrazepam is not an aphrodisiac, it is a hypnotic drug, belong to the benzodiazepine family of Librium, Xanax, and Valium, with 10 times the potency of diazepam (Valium). Its hypnotic effects predominate over its sedative, anxiolytic, muscle relaxant, and anticonvulsant effects. Flunitrazepam is also commonly used to potentiate heroin's effects or modulate the stimulatory effects of cocaine. It enhances low-grade heroin, alleviating anxiety, insomnia, and withdrawal symptoms.
     It is sold as individually wrapped tablets that are colorless, odorless, and tasteless when mixed in beverages - physicial properties that make it a favorite for spiking beverages and punch at fraternity parties. Alcohol is synergistic with flunitrazepam and results in quicker intoxication. There are some reports of grinding and snorted / intranasal use. On the street, each dime-sized white tablet costs between $1 and $5.
DESIRED EFFECTS
Desired effects include disinhibition, amnesia, and muscle relaxation, but individual effects vary. The amnesia is anterograde, that is, it involves memory loss for events that occur after the medication is taken.
ADVERSE EFFECTS
Adverse effects include sedation, respiratory depression, impaired motor coordination, confusion, memory loss, hallucinations, and potential overdose when combined with alcohol. Sedation typically occurs 20 to 30 minutes after ingestion and lasts several hours. Paradoxically, it may cause aggressiveness in some cases.
MANAGEMENT OF ROHYPNOL OVERDOSE
Rohypnol is not detectable with routine urine toxicology screen. Airway protection and blood pressure control may be warranted. Midazolam (Versed), used as a sedative before endoscopy, can be used in severe cases to reverse benzodiazepine effects, but longer observation would be indicated. 

CLUB DRINKS
Smart Drinks
In addition to alcohol, marijuana, cocaine, and amphetamines, the rave subculture also have a variety of energy-boosting stimulant cocktails called "smart drinks," also called "power drinks," which are used to prevent dehydration. They are sold at both raves and nutrition stores and come in bottles or cans or as powders or capsules. They come in a variety of fruit-flavored herbal blends that may contain ma huang, caffeine, guarana (a stimulant similar to caffeine extracted from the crushed seeds of Brazilian vine, Paullinia cupajna), ginseng, chamomile, amino acids, taurine, sugars, tryptophan, electrolytes and high doses of B and C vitamins. They may also be mixed with some "key" ingredients ­ kava, ginkgo, yohimbe, dong quai ­ depending on what type of "vitality" one is looking for.
     Gorno Juice is a mixture of liquid kava (a muscle liniment formulation) and Morning Glory seeds.
     Crunch Berries is Magnolia red berries crushed in gin.
     LIQUID X refers to a concoction that contains liquid kava and ecstasy.

Go-go Drinks
Go-go drinks, similar to powder drinks, are also sold at raves and contain ginseng, yohimbine, and guarana. They are marketed as "Viagra for women." They are used to boost energy levels, to increase stamina, to quench thirst, and to enhance concentration. Most contain stimulants. Taken in excess they can cause nausea, loss of appetite, insomnia, tachycardia, visual and sensory impairment, and bladder and urinary tract discomfort. People with heart or kidney disease, hypertension, hypotension, asthma, and diabetes mellitus should not use them.
Red Bull soda, loaded with caffeine, vitamins B6 and B12, and amino acids, popular in UK and Europe, has made inroads into the U.S., thick and syrupy when drank straight, but for the "buzz" is taken with a shot of vodka over the rocks.

Roboshot
A popular trend is combining alcohol with over-the-counter drugs. An example of an alcohol-drug combination is "roboshot" - 1-2 ounces of robitussin DM chugged with a 12 ounces of beer. Allegedly, this produces a "buzz" equivalent to a six-pack of beer, without any hangover.